“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

[Northeast Agent]

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Treatments

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.

www.propublica.org

Over the years, medical groups have repeatedly complained that EviCore's guidelines were outdated and rigid, resulting in inappropriate denials or delays in care. Frustration with the rules has led some doctors to refer to the company as EvilCore. There is even a parody account on X.

It works with more than 100 insurers across the country, including industry titans such as UnitedHealthcare, Aetna and Blue Cross Blue Shield and some Medicare and Medicaid contractors. Cigna took over the company in 2018, but EviCore maintains its independence by blocking insurers from prying into one another's proprietary data.

 

[Newby]

Is this why doctors and nurses are hating on Advantage Plans?

 

[DonP]

Is this why doctors and nurses are hating on Advantage Plans?

No the main reason the medical profession hates Medicare advantage is money . I bet 80% of Medicare advantage clients are lower middle income to low income . With routine $200-$300 copays for mri's , X-rays etc and hospital stays of $400 a night . You think 90% of these copays are ever paid ? Heck no . You walk in with a fat sup and the dr orders all the tests he wants and he's paid 100% of what his contract speculates . No question the biggest question I get is why am I billed for this and that ? Mrs Walters id be glad to sell you a sup and pdp at $230 a month but you rx's will also cost you $1000 more got the yr . No question if you can afford it a plan n much better medically than a mapd .

 

[somarco]

Don, you really are delusional . . . may be time to up the dosage on your meds.

 

[rmhaire]

Don, you really are delusional . . . may be time to up the dosage on your meds.

What I'd like to know is the name of that hospital that only charges $400 a night.

 

[straightnochaser]

These MSO dudes above have no idea how mapd works, it's embarrassing.. they should be embarrassed

 

[rmhaire]

These MSO dudes above have no idea how mapd works, it's embarrassing.. they should be embarrassed

Typical response from a one trick pony.

What else you got?

 

[straightnochaser]

Typical response from a one trick pony.

What else you got?

One trick pony? I sell multiple lines of insurance.. put me back on ignore, I preferred it that way.

 

[rousemark]

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Treatments

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.

www.propublica.org

Over the years, medical groups have repeatedly complained that EviCore's guidelines were outdated and rigid, resulting in inappropriate denials or delays in care. Frustration with the rules has led some doctors to refer to the company as EvilCore. There is even a parody account on X.

It works with more than 100 insurers across the country, including industry titans such as UnitedHealthcare, Aetna and Blue Cross Blue Shield and some Medicare and Medicaid contractors. Cigna took over the company in 2018, but EviCore maintains its independence by blocking insurers from prying into one another's proprietary data.

Believe the company name is misspelled. It should be eviLcore.

 

[scagnt83]

EviCore is not evil..... the carriers who use EviCore are the evil ones.

The carriers could say "no".

Carriers could say "that will negatively impact the health and well being of our policyholders".

Instead, carriers say "yes", knowing exactly how EviCore will impact the lives of their policyholders.

Yet some people want to give these profit driven health care companies even more control over our healthcare system.